Beware Monkey Traps

It is said you can trap a monkey by putting a nut through a small hole in a gourd. The monkey reaches in and grabs the nut, but then his fist won’t fit back through the hole. Greedy monkeys will literally let themselves be caught rather than let go of the nut. So far, no commenter on my essay seems willing to let go of the nut of effective medicine, held in the gourd of the second half of medical spending.

As an analogy, imagine you ran a software company, whose many offices had different wage levels and work cultures, with average work hours ranging from seven to fourteen per day. Surprised to see these offices were equally productive, you randomly changed wages, inducing changes in work hours. You again found offices that worked more did not produce more; after seven hours people got tired and added as many bugs as they fixed. If instead of just cutting wages to get only seven hours of work, you just told everyone "watch out for bugs," you would be in a monkey trap, refusing to let go of the nut of productive work in the gourd of extra work hours.

So begins my first reply at CATO Unbound. I go on to argue that it is a monkey trap that keeps health policy experts from endorsing my proposal to "Cut Medicine In Half." You might think that humans wouldn’t fall for such a simple trap, but consider our military policy of "Leave No Man Behind":

Depicted in the film Black Hawk Down, this mission resulted in the deaths of 18 soldiers. In fact, the strategy of enemy Somali militiamen focused on the American policy of not leaving any soldier behind; they knew that if they managed to shoot down a helicopter, the Americans would move in to defend the helicopter’s crew.

Since I suggest "showing that you care" signals explain our inclination toward excess medicine, and solidarity signals are said to explain "leave no man behind," perhaps monkeys are inclined to never let go of food as a signal to would-be thieves.

I think that doctors and medical academics value health gains far more than other types of consumption. Try this proposal:

“Let us crudely cut spending by 30% by reducing subsidies and adding copays/deductibles, and use a big chunk of the savings to increase the NIH budget tenfold, funding numerous massive head-to-head randomized clinical trials to sort out medical quality, and developing new therapies that have beneficial effects as unambiguous as antibiotics, vaccines, and eyeglasses.”

Unknown Healer

“Plus throw in a few tens of billions for deworming, oral rehydration therapy, etc in the developing world to save a hundred million lives or so.”

Eric Hansen

“Do you argue that it is immoral to ever “leave a man behind” to disease, even if this tends to hurt as many in the attempt as it helps?”

Would these crude price cuts leave behind a type of man? While it can be argued that negatively affecting random outliers for the betterment of all is just, systematically leaving behind a socioeconomic group would be an untenable position.

http://www.bbnflstats.com Brian

I realize this is not your main point, but:

The leave-no-man-behind ethic has a valuable military purpose beyond personal loyalty. It allows servicemen to take additional rational risks knowing that if he is captured, wounded, or shot down, he will not be abandoned.

I can tell you as a former Navy fighter pilot, the leave-no-man-behind ethic allowed me to focus more on defeating the enemy than preserving my own neck.

The 18 soldiers lost in Mogadishu saved countless other lives and served a purpose broader than simply retreiving fallen comrades. Their valiant sacrifices proved the warrior ethic was alive and well in the US military.

J Thomas

I read about an example of the monkey trap problem. It was probably an urban legend, though it was reported with names. A gorilla had escaped in NYC and was cavorting around on some important bridge. The police were supposed to catch him. One of them remembered the monkey trap and tried to make one. The gorilla reached into the trap and grabbed the food. Then his hand wouldn’t come out of the trap. So he smashed the trap against a girder and ate the food and climbed back out of reach.

Of *course* we don’t want to give up effective medicine so we can have low-cost medicine. What we want is effective low-cost medicine.

My natural prejudice is to establish a giant database that includes some of the details of everybody’s medical records. Go to some lengths to keep them anonymous, and make it illegal for people to reverse-engineer it to find individual data and also establish the custom that “people just don’t do that”. Most people would be willing for some of their records to be public anyway, to help others who have the same problems.

So anybody who has the time and a bit of expertise could look at a specific topic and see what’s going on, to the extent of their ability to handle the data.

So for example, my guess is that people with some psychiatric problems get better and worse over a period of months. Their psychiatrists prescribe one medication for them after another until they get better, and that one is presumed to work. Then each time they get worse the dosage is increased. When the dosage reaches dangerous levels then they get switched to different medications until they get better again, and the cycle repeats. That’s only a guess, but if the data was available it could be tested.

If patients believed that particular medications were ineffective they wouldn’t accept them, and those particular ineffective expenses would be reduced.

Don’t let go of the goal. Break the trap.

http://www.hopeanon.typepad.com Hopefully Anonymous

I like Unknown Healer’s 9:45am post. I also appreciate Robin’s “leave no man behind” example, although Brian provides interesting context. Still, I don’t think that context ends the discussion: it still seems of value to weigh the benefits of the bravery that policy encourages against the costs of actually following that policy. Also, for example, would prize incentives for bravery be more effective and less costly than “leave no man behind” policies.

http://www.mccaughan.org.uk/g/ g

If I were contemplating some action that would put my life in danger, then I think I’d be much more encouraged to do it by knowing that a bunch of other people would be taking extreme measures to save my life if possible than by knowing that if I happened to survive I might get a prize.

Then again, if it’s true that the leave-no-man-behind ethic ends up losing more lives than it saves (and I have no idea whether it does), a moderately altruistic military person might reason: sure, my life is in less danger because of this, but it could also end up costing several of my fellow personnel their lives too, and on average I’m risking more lives than if it were only me at risk. Which might end up reducing bravery rather than enhancing it.

Perhaps the military doesn’t tend to recruit people who think that way. Or perhaps scarcely anyone really thinks that way when their own life is in real and immediate risk.

http://profile.typekey.com/robinhanson/ Robin Hanson

Brian and all, yes, if soldiers can become much less effective because they fear no one will come to save them, this benefit may outweigh the cost. But it is hard to see a similar benefit in medicine.

J, cutting medicine won’t stop or even slow us from implementing your proposal. Why not cut?

J Thomas

J, cutting medicine won’t stop or even slow us from implementing your proposal. Why not cut?

Robin, you are interested in a different problem from the problem I’m interested in.

I want to cut ineffective medicine and promote healthy practices of all kinds. This should reduce medical costs considerably as a side effect.

As I understand it, you want to cut medical costs, and you hope that it won’t result in poorer health.

I don’t see that our goals are opposed, they’re more off at skew angles. My thought is that if (as you think) we’re now spending our money irresponsibly, we might easily cut the funding, spend the money on something else irresponsible like another war, and mess up whatever valuable things we might be doing with the medical money. Since we don’t know which of the current spending is useful, when we cut, it might easily turn out that we preferentially cut the valuable things and fund the useless or harmful ones.

So I figure — when you don’t know what you’re doing, it’s a good idea to find out. I’d rather first figure out what to cut and then cut that, than make random cuts and hope it works out right by accident.

I particularly dislike making great big changes when we don’t know what we’re doing. We might try to reduce the rate of increase in medical costs, or perhaps even try to freeze total costs (while the population is rising) rather than cut costs in half blindly. It makes sense to be conservative when you’re dealing with things you know you don’t understand. And yet, there’s no guarantee that there would be any bad effect from random cuts. If my approach worked, it would free up money for you to cut without bad effects. My approach would aid yours, so why not measure?

Unknown Healer

J,

What about the proposal of multiplying the NIH budget severalfold with a fraction of the savings from Robin’s plan, and using much of the increase to do comparative efficacy studies?

J Thomas

UH, I think that’s a promising idea. I would like to see the data become public, and watch lots of amateurs analyse it wrongly.

As it is, professionals get it wrong a whole lot. Would we do worse with more openness? Get data not just on studies intended to test particular points. Get data on the result of procedures in common practice. What’s the harm?

joe

Unknown healer,

“What about the proposal of multiplying the NIH budget severalfold with a fraction of the savings from Robin’s plan, and using much of the increase to do comparative efficacy studies?”

The problem with this plan is that is that as it currently stands, because of aggregate correlation studies, Robin doesn’t believe most of the results from comparative efficacy studies anyway. He sees the results of clinical trials as contradictory to the results of aggregate correlation studies and concludes that clinical trials must be unreliable as sources for information regarding efficacy of medicine.

Unknown Healer

“The problem with this plan is that is that as it currently stands, because of aggregate correlation studies, Robin doesn’t believe most of the results from comparative efficacy studies anyway. He sees the results of clinical trials as contradictory to the results of aggregate correlation studies and concludes that clinical trials must be unreliable as sources for information regarding efficacy of medicine.”
Robin certainly endorses running RAND II, The Big One. Most folks would be getting the crudely cut amount, some would be getting the current system, and others would get care that had been pruned by medical experts to try to selectively prune the bad while increasing the good.

Plus, I think that Robin accepts the benefits of vaccines, antibiotics, eyeglasses, antiretrovirals for HIV treatment, beta-blockers following heart-attacks, etc. Surely he would agree that the reallocation of the cut funding to research as an improvement over the present situation.

Robin, am I right?

http://profile.typekey.com/robinhanson/ Robin Hanson

Joe and Unknown, the best data is aggregate randomized experiments.

Doug S.

Which might end up reducing bravery rather than enhancing it.

That might be the point, actually – keeping a soldier from doing something stupid because if he screws up, his buddies are going have to risk themselves to pull his ass out of the proverbial fire, and it will be his fault.

joe

Robin, that all depends on what you are randomizing and how that relates to your question of interest. What you call an experiment should really be called an OBSERVATIONAL STUDY since you are leaving too much control in the hands of study participants.

joe

If people are left to choose marginal heath increases, and you find no health benefit, does this mean that there is no health benefit to a marginal increase in medicine? Or could it mean that people are not very good about choosing their own marginal health increases, as well as possibly when to seek them. The two conclusions are subtly different, but have vastly different implications for the efficacy of marginal increases in medicine.

If you are so confident we can reduce medicine, and you know in what areas, why don’t you design a study surrounding different pre-specified conditions as well as differing treatment regimens for them. Give some people a reduced treatment regimen that is less than doctor recommended. You should have no problem with this ethically since you don’t think it’s going to hurt them anyway.

http://www.hopeanon.typepad.com Hopefully Anonymous

To improve medical/economic efficiency, we may also want to consider government buy-outs to immediate family members to allow the state to euthenize people with debillitating age, illness, and disability, where we don’t gain anything useful (such as medical trials) from keeping them alive. But before that it makes sense to make euthenasia legal. I think it becomes rational even from a “but it could happen to you” perspective if we hitch this policy to the degree the economic efficiency without the policy would make us more likely to die in the future than an achievably optimized implementation of the policy.

joe

HA, are you human, or a computer program designed to selfishly maximize its personal odds of persistence at all costs? Were you programmed with the answer to the question “what does it mean to be human?”

Pessimistic about Anonymous AIs

joe,

If that were the case we would presumably have been converted into computronium or otherwise devoured by now.

Doug S.

I think HA was being ironic.

http://entitledtoanopinion.wordpress.com/ TGGP

It is not at all ironic for HA to say that since it is entirely in keeping with the things he has said before.

Floccina

“I want to cut ineffective medicine and promote healthy practices of all kinds. This should reduce medical costs considerably as a side effect.”

Healthy practices do not reduce medical costs rather they appear to extend life.

J Thomas

Healthy practices do not reduce medical costs rather they appear to extend life.

I would expect them to reduce medical costs per person per year.

http://nordsieck.net nordsieck

Contrary to your implication, “leave no man behind” is a rational meta-strategy for a superpower. The US traded 18 dead for something like 1000 dead, in addition to a large chunk of Bakara market destroyed. Any militia group that cares about the lives of its members will remember this event than think twice about attacking US servicemen (people). In its effects, it the strategy is almost identical to “we don’t negotiate with terrorists” – the people lose in the short run, but win in the long term.

http://entitledtoanopinion.wordpress.com/ TGGP

nordsieck, the U.S never succeeded in its goals in Somalia. The place is still a mess.

J Thomas

Doesn’t the success of such strategies depend on how the enemy responds?

Facing multiple enemies it’s natural for one of them to try to get US servicemen to disappear in places they want us to attack. Let us waste our strength attacking their enemies.

Any consistent behavior lets the enemy game us.

joe

Robin,
I am very curious to read your response to my criticisms raised on 6/20 at 6:19PM and 6:33PM.

BillK

According to the statistics, the US has huge expenditure on medical costs, but little to show in return, in comparison with many other countries.

Comparisons between countries using statistics is a very shaky situation. Definitions vary between countries. For example, in the UK violent crime includes children stealing mobile phones from each other. This would only be classified as theft in many countries, and not even recorded in others.

The US has very advanced, expensive medical technology and expensive drugs. Much of this is not available in less rich or less advanced countries.

In the US, 70% of medical expenditure is spent in the last five years of life. 35% in the last year of life. This expenditure obviously provides little measurable benefit in the health statistics. This high end-of-life expenditure is either not available in many countries, or they choose not to spend a lot on old, dying people.

Controlling the end-of-life expenditure would radically improve the US position in the health statistics league table.

There are other problems, of course, but that one factor overwhelms all others.

BillK

http://profile.typekey.com/robinhanson/ Robin Hanson

Bill your 70% and 35% figures don’t sound right to me – do you have a source?

BillK

You probably have access to many more medical studies than I have. 🙂

I thought that economists generally acknowledged that the high cost of dying was a problem for US medicine.

Quote:
The overwhelming preponderance of U.S. health care costs now arise in the final years of life. Indeed, if one were to estimate costs across a life span, the shape of the expenditures reflects the new health and demographic circumstances. Figure 1 presents a rough estimate of health care costs distributed across the average American’s lifetime. The final phase of life, when living with eventually fatal chronic illnesses, has the most intense costs and treatments. A similar curve for the U.S. population in 1900 would have been flatter, both because serious illness was more common throughout life and because death often occurred suddenly. Neither clinical services delivery nor Medicare has kept pace with the changes in the pattern of needs that underlie these costs.
————

Figures may vary depending on what costs you include. Medicare and non-Medicare expenditure, hospitalization costs, nursing home and hospice costs, etc. Part of the problem is that sick, old people have a lot wrong with them and the doctors don’t know in advance whether they are going to die, so they may receive aggressive treatment that is not really justified.

But whether the percentage is 70% or 50% doesn’t really alter the argument much.

BillK

http://profile.typekey.com/robinhanson/ Robin Hanson

Bill, that source does not give specific figures.

BillK

How would you interpret:
“The overwhelming preponderance of U.S. health care costs now arise in the final years of life”.

But anyway the numbers are hidden in the many references quoted in that study.
(I haven’t read them all – that’s your job) 🙂

It starts with:
About one-quarter of Medicare outlays are for the last year of life, unchanged from twenty years ago. Costs reflect care for multiple severe illnesses typically present near death.

Then later on it points out that:
Medicare paid 61 percent of decedents’ costs, Medicaid paid 10 percent, and other payers paid 12 percent. Out-of-pocket costs accounted for 18 percent.

————————

But surely these figures are well-known?
The cost of final years’ medical treatment in the US is much discussed, as it is very relevant to the baby-boomer generation.

BillK

http://profile.typekey.com/robinhanson/ Robin Hanson

Bill, this fact sheet says Medicare benefits are 20% of total U.S. medical spending. So one-quarter of Medicare benefits is 5% of total spending, much less than your 30% figure.

http://www.hopeanon.typepad.com Hopefully Anonymous

Robin, thoughts about these numbers beyond correcting the details of foil BillK?

http://www.mccaughan.org.uk/g/ g

BillK, you originally gave some quite specific figures: 70% and 35%. Where did those particular figures come from? I agree that if the correct figures turned out to be 50% and 20%, or 80% and 30%, or whatever, then it wouldn’t make a big difference, but I’m still curious where you got your numbers from.

Robin, is there reason to think that medical treatment in the last year of life is all, or almost all, done by Medicare? (That’s a genuine question; I’m very ignorant.) If not, then the fact that the most conservative lower bound available from BillK’s citation is 5% isn’t quite to the point.

Douglas Knight

g,
the 61% that BillK quotes seems to answer your question. But it bumps the 5% up to 8%.

joe

Robin,
What about all the people who die each year but were not old enough for Medicare benefits?

BillK

Sorry. At the moment I am unable to find a ‘fact-sheet’ or even a RAND study that quotes the exact percentages I mentioned. But arguing about the exact percentage is avoiding the point that, for example, over half of medical expenditure is spent in the final years of life, when it will make little difference to the health benefits statistics.

You’re the health statistician – what do you think the percentages are?

There are two scenarios at work here, which confuses the statistics.

Firstly, the general point, which I don’t think anyone disputes, is that medical costs for the elderly (over 65s) is much higher than for younger ages.

The distribution of health care costs is strongly age dependent, a phenomenon that takes on increasing relevance as the baby boom generation ages. After the first year of life, health care costs are lowest for children, rise slowly throughout adult life, and increase exponentially after age 50 (Meerding et al. 1998). Bradford and Max (1996) determined that annual costs for the elderly are approximately four to five times those of people in their early teens. Personal health expenditure also rises sharply with age within the Medicare population. The oldest group (85+) consumes three times as much health care per person as those 65-74, and twice as much as those 75-84 (Fuchs 1998). Nursing home and short-stay hospital use also increases with age, especially for older adults (Liang et al. 1996).
———-
About half of all health care expenses in a person’s lifetime occur after age 65
Alemayehu, B. and K.E. Warner (June 2004). “The Lifetime Distribution of Health Care Costs.” Health Services Research, 39(3), 627-642.
———–

The high proportion of medical costs invested in the elderly produce relatively small gains in extended lifespan.

Secondly, when younger people become seriously ill, then typically very aggressive and expensive treatments will be used to try to save their life. Although, in total, these sick younger people are fewer in number than the elderly, if they die, then their medical costs should be added to the ‘final years of life’ total medical costs.

If you add, say ~20%, for younger deaths, to the ~50% for older deaths, then you are around the 70% figure I quoted for ‘end-of life’ medical costs.

I must say though, that I find all these medical statistics reports rather confusing. But I think the overall conclusion still holds – that high ‘end-of-life’ medical costs is the main factor in making the US health stats look bad.

The Burden of Chronic Diseases and Their Risk Factors:
National and State Perspectives 2004

Preface:
Chronic diseases such as heart disease, cancer, and diabetes are leading causes of disability and death in the United States. Every year, chronic diseases claim the lives of more than 1.7 million Americans. These diseases are responsible for 7 of every 10 deaths in the United States. Chronic diseases cause major limitations in daily living for more than 1 of every 10 Americans, or 25 million people. These diseases account for more than 70% of the $1 trillion spent on health care each year in the United States.

http://www.mccaughan.org.uk/g/ g

But that isn’t at all what you said. “70% of medical spending goes on the last five years of life” and “70% of medical spending goes on heart disease, cancer and diabetes” have *nothing* to do with one another beyond both mentioning “70% of medical spending”.

I’m sure you’re right that (1) a lot of US medical spending is on people near the ends of their lives, (2) quite a lot of it is on people *very* near the ends of their lives, and (3) it might be effective, in terms of getting more QALYs-per-buck, to reduce that. But (and I’m sorry to be repeating myself here) you quoted a couple of quite specific figures, and there doesn’t yet seem to be any evidence that you weren’t just making those figures up. And I don’t think you should do that.

One other thing. Suppose you get cancer at 30 and die three years later. Then any medical treatment you got during that time will have been “in the last 5 years of life”. It seems to me that this discussion has been framed so as to make end-of-life treatment sound as if it’s all aimed at enabling people to live to 93 instead of 92. Unless we know what fraction of this end-of-life treatment was actually aimed at enabling people to live past 33 instead of dying then but happened not to succeed, I think a discussion on those terms is inviting all sorts of broken intuitions.

Anyone got any figures for what fraction of medical expenditure is on treatment of people *who would have been within N years of death even without the particular problem the expenditure was trying to deal with*?

BillK

The doctor who quoted the original percentages has got back to me.
He works as an Emergency Room director in a large hospital.

He says that there is no point in referencing studies and reports as they all have different numbers and you can get support for almost any figure you fancy.

He says that his 70%/5 years and 35%/1year spending estimate is a very conservative consensus view. In some cases over 90% is spent in the last year of life.

That says
The overwhelming preponderance of U.S. health care costs now arise in the final years of life. Indeed, if one were to estimate costs across a life span, the shape of the expenditures reflects the new health and demographic circumstances. Figure 1 presents a rough estimate of health care costs distributed across the average American’s lifetime.

The graph shown in Fig.1 on page 1 of this whitepaper certainly agrees.

BillK

http://www.mccaughan.org.uk/g/ g

So I take it that the original 70% and 35% figures were in fact pulled out of the air (though apparently not by you but by the doctor you now mention) as representatives of the less precise but more accurate statement that “The overwhelming preponderance of US health care costs now arise in the final years of life”. As I said, I don’t think you should do that.

For the benefit of anyone who hasn’t taken a moment to look at figure 1 of that white paper, I’ll mention that its x-axis has exactly three labels (“Birth”, “Life span”, “Death”), its y-axis exactly one (“Expenditure”), and that it seems obvious that the curve it shows was drawn freehand and not directly derived from any actual data.

joe

Why are we arguing about something that is probably true? Does anyone here actually not think that a significant portion of healthcare costs accrue during the last few years of life?

What about you, g?

http://www.mccaughan.org.uk/g/ g

I answered that last question before you asked it (2007-09-23, 18:23).

As for arguing about something that’s probably true: (1) what I’m “arguing” about is whether BillK’s figures were just made up or not, which seems to me to be of some interest whether or not they’re roughly right, (2) I gave some reasons for being suspicious about any argument founded merely on the fraction of expenditure in the last year / N years of life, (3) even when there’s general agreement that something is probably true there’s scope for discussion about how probably it’s true and how strongly it should be stated for best accuracy, and (4) sometimes something can be very widely believed but still false.

In this instance, it seems that there’s plenty of folklore to the effect that US healthcare costs for people close to death are very high, and that this indicates that a lot of resources are going into extending lives that aren’t going to last long (or: whose quality isn’t very high regardless) anyway. But it’s still not very clear whether there’s much more than folklore. The fact that the authors of that RAND report from 2003 chose to draw that astonishingly unquantitative Figure 1 suggests to me that there aren’t any good figures to be had. (Or that there are, but that they don’t look as convincing as the impressionistic Figure 1.) I hope I’m wrong, since these seem like vital facts that need to be taken into account in framing healthcare policy.

Douglas Knight

Anyone got any figures for what fraction of medical expenditure is on treatment of people *who would have been within N years of death even without the particular problem the expenditure was trying to deal with*?

Such figures would involve knowing if medicine actually works. It may be possible to figure out how much money is spent on 30 year-olds with cancer and break it into the groups who survived & those who didn’t, but I doubt that the cancer medicine saved anyone.

http://www.mccaughan.org.uk/g/ g

Are you using “medicine” in a startlingly narrow way, or have I spectacularly misunderstood you, or did you really just say that you doubt that treating cancer saves any lives?

joe

God can giveth the cancer, and he can taketh it away. G, don’t you believe in miracles? 🙂

Tim Collardey

I’m new to this discussion, so I’m not sure if this point has been made yet, but I don’t hear many folks these days when discussing the cost of health care raise the question about the ROOT CAUSE of the mess it all is. In my mind, focusing on the health system is looking at symptoms or consequences, not sources or causes. Imagine the impact on health care if people received better education about their own bodies, felt empowered by that knowledge, and took more of their own responsibility to be healthy. So many people are of the mindset “full steam ahead, damn the torpedoes!” when it comes to their lifestyles, figuring “the doctor will fix it” when they get sick or injured. It is a classic case of co-dependency in our society, where the sick need the health professionals, and the health professionals NEED the sick (an unhealthy society is, after all, great job security!)

How do we wake up the sleeping “beast” that is the vast majority of Americans who won’t do preventively for themselves what no advertisement campaign in the world will “fix?” Sure, we can see some progress over the years, most notably, the decrease in tobacco dependency. Maybe we’re even exercising more. But the increase in childhood obesity and diabetes alone should scare the hell out of all of us. There are no quick fixes for those conditions. To me, they’re the “canaries” in the dark cave of health care. Kids depend on us for education, and they obviously aren’t getting it. And we aren’t giving it.

The cynical side of me says a lot of corporations stand to benefit from keeping the masses in the dark about their bodies and good health. Does anyone LIKE the proliferation of drug commercials on TV? And what do so many of them suggest: “talk to your doctor about Drug X.” We’re going to experience a great deal of pain and financial drain before the cart gets put in back of the horse where it should be. I’d like to hear just one Presidential candidate suggest this approach instead of all the other crap I’ve heard so far. Anyone else with me on this?

This is a blog on why we believe and do what we do, why we pretend otherwise, how we might do better, and what our descendants might do, if they don't all die.